Clinical management of dental anomalies

Question 1

Hypoplastic form of amelogenesis imperfecta with gross calculus deposits

Answer 1

Calculus as too sensitive to brush - practically no enamel formation
Management with full composite crown coverage and preformed metal crowns

Question 2

Genetic anomalies of dentine

Answer 2

Dentinogenesis imperfecta - loss of enamel with brown/ yellow opalescent dentine - which wears rapidly
-DSPP mutation affecting non-collagenous proteins; variation in severity of presentation
Radicular dentine dysplasia - radicular pathology; aetiology unknown
DI with OI (syndromic) - collagenous proteins affected

Question 3

Dentinogenesis imperfecta epidemiology (3)

Answer 3

Prevalence 1:6000
Usually autosomal dominant inheritance
Primary and Secondary dentitions – but primary always more severely affected

Question 4

Dentinogenesis imperfecta clinical features (2)

Answer 4

Enamel usually fractures off early due to lack of dentine support. Soft exposed dentine then quickly wears

Question 5

Dentinogenesis imperfecta histological features (1)

Answer 5

Irregularly formed and poorly mineralised dentine

Question 6

Dentinogenesis imperfecta radiographic features (3)

Answer 6

Bulbous crowns, short thin blunt roots, obliteration of root canal

Question 7

Clinical considerations of treating A and DI (4)

Answer 7

Masking of underlying discolouration
Reduced shear bond strength of resin composites
Orthodontic management
-would rather use removable appliances due to bonding problems
Life-long maintenance of restorative interventions

Question 8

Tooth morphology anomalies (4)

Answer 8

Dens in dente / dens invaginatus
Dens evaginatus + talon cusp
Double teeth (Fusion, Germination)
Microdontia - peg/conical lateral incisors

Question 9

Principles of management: tooth morphology anomalies (3)

Answer 9

Early diagnosis of dens-in-dente - as subsequent RCT is difficult, aim to fissure seal / occlude communicating channels or caries-prone sites
Judicious grinding of talon cusps + duraphat applications after root formation is complete
Management of double teeth - very complex, seek specialist opinion (orthodontic assessment) management is dependant on pulp morphology

Question 10

Talon cusps - facts and figures (6)

Answer 10

Prevalence: uncommon, increased in some racial groups (7.7% North Indian population; 0.17% American population; 0.06% Mexican population)
Increased in males (2:1 male:female)
More common in maxillary teeth
3 times more common in permanent dentition than primary dentition
The maxillary lateral incisor is the most frequently affected tooth
Labial surface of teeth may also (uncommonly) be affected
IF PT HAS TALON CUSP - LOOK OUT FOR OTHER DENTAL ANOMALIES AS WELL

Question 11

Talon cusps - aetiology (5)

Answer 11

Multifactorial (polygenetic and environmental factors involved) disturbance of tooth formation
Familial associations
Increased prevalence in patients with consanguineous parents
Increased prevalence in some syndromes (e.g Ellis-van Creveld; Rubinstein-Taybi; Sturge-Weber)
May be associated with other dental anomalies (e.g supernumerary teeth; dens invaginatus; microdent lateral incisors; shovel-shaped incisors; bifid cingulum; enlarged cusps of Carabelli)

Question 12

Talon cusps - clinical problems (5)

Answer 12

Occlusal interference which may lead to: displaced teeth; TMJ dysfunction; acute apical periodontitis
Caries
Poor aesthetics
Tongue irritation
Attrition or fracture of cusp with pulpal exposure and ensuing pulp necrosis

Question 13

Is there pulpal tissue in the talon cusp? (4)

Answer 13

You can not be sure!
Histological studies have shown some talon cusps do contain pulpal extensions and others do not
Radiographs are of little diagnostic help
Large talon cusps that project away from the tooth surface are the MOST likely to contain pulpal tissue

Question 14

Talon cusp tx: caries prevention (2)

Answer 14

Early use of fissure sealant or composite to occlude caries-prone fissures between talon cusp and tooth surfaces
Give appropriate oral hygiene instruction

Question 15

Talon cusp tx: cusp reduction (5)

Answer 15

Be aware of possibility of pulp exposure
Objective is to undertake GRADUAL cusp reduction with reparative dentine formation (and pulpal recession)
-you can do it all at once if pt wants but try to wait until the root is mature in case you expose! Put Dycal on
Literature suggests variable time intervals: 4 weeks, 6 weeks, 8-weeks, 4 months (go for 3 months)
1-1.5 mm of tooth tissue reduction recommended each visit
Placement of F varnish after each visit to desensitise exposed dentine

Question 16

Dens-dente (2)

Answer 16

Can get sinus

Would be sent to endodontist as so narrow - high chance of failure

Question 17

Double tooth management

Answer 17

Take radiograph
See what root morphology is like
Multidisciplinary case
Different ways to treat e.g. make it look like one tooth; raise a flap and split the teeth

Question 18

Tooth colour anomalies (8)

Answer 18

Be aware of possibility of pulp exposure
Objective is to undertake GRADUAL cusp reduction with reparative dentine formation (and pulpal recession)
Literature suggests variable time intervals: 4 weeks, 6 weeks, 8-weeks, 4 months
1-1.5 mm of tooth tissue reduction recommended each visit
Placement of F varnish after each visit to desensitise
exposed dentine

Question 19

Management of tooth colour anomalies (5)

Answer 19

Tetracycline staining usually resistant to bleaching attempts - may have to resort to veneers
Microabrasion first line of treatment for most superficial intrinsic enamel staining
Tooth whitening with commercial products (carbamide peroxide) (See GDC guidance!)
Resin infiltrataion (ICON)
Veneers - direct / indirect composite with opaquers

Question 20

Anomalies of tooth number (2)

Answer 20

Hypodontia, mild (<2), moderate (3-5) and severe (>6) missing permanent teeth, excluding 8s (anhydrotic ectodermal dysplasia)
Hyperdontia ( cleidocranial dysostosis)

Question 21

Clinical significance/ rationale for treatment: hypodontia (3)

Answer 21

Poor aesthetics
Compromised function
Loss of vertical dimension

Question 22

Principles of management: hypodontia (6)

Answer 22

Multidisciplinary approach - orthodontic, paediatric dentistry & restorative input
Maintain dentition - PREVENTION!!!
Orthodontic management of spacing
Partial dentures
Adhesive dentistry
Implants

Question 23

Hypodontia: problems of management (5)

Answer 23

Pt compliance
Small crowns
Lack of undercuts
Lack of alveolar bone
Loss of vertical dimension

Question 24

Clinical significance/ rationale for treatment: hyperdontia (3)

Answer 24

Poor aesthetics
Malocclusion - impediment to tooth eruption
Pathology associated with unerupted teeth - resorption of adjacent teeth; follicular changes

Question 25

Principles of management: hyperdontia (5)

Answer 25

Early diagnosis - appropriate radiographs
Orthodontic opinion re supplemental teeth?
Referral for surgical removal if necessary
SPACE MAINTENANCE where necessary
Review of unerupted teeth

Question 26

Anomalies of tooth eruption (3)

Answer 26

Infraocclusion
Primary failure of eruption
Ectopic or failed eruption

Question 27

Clinical Significance / Rationale for Treatment: Infraocclusion (2)

Answer 27

Malocclusion

Caries/ periodontal disease

Question 28

Principles of management: infraocclusion (4)

Answer 28

Take rads to see whether there is a permanent successor underneath
Early diagnosis - regular review, photos, study models, usually only monitoring is necessary
Orthodontic opinion where successor is absent
SPACE MAINTENANCE where necessary, composite onlay, GIC, PMC, Overdenture
Early extraction to avoid need for more complex surgery, care with ankylosis